Involuntary movements, usually occurring after months or years of antipsychotic treatment. The most common symptoms are oro-buccal-lingual, such as chewing, lip smacking, and tongue protrusion. Occasionally causes movements of fingers or toes and rarely, in severe cases, may affect torso and gait. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Tasimelteon is a melatonin receptor agonist approved for non-24-hour sleep-wake disorder (N24SWD), which occurs primarily in blind people. Due to its high price (even for the new generic version), you may want to consider ramelteon instead. While ramelteon hasn’t been studied in patients with N24SWD, it’s reasonable to try because it is so similar pharmacologically yet much more affordable. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

SAMe is a natural methyl donor important in neurotransmitter synthesis and function. Several clinical studies (lasting up to 42 days) have shown that taking SAMe is more effective than placebo and appears to be as effective as tricyclic antidepressants, though the studies were limited in various ways. Consider using it for those patients with mild to moderate depression who are interested in using alternative therapies, or as an augmentation strategy in partial responders. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Dopamine agonists are effective first-line agents for restless legs syndrome (RLS), though rates of problematic impulsive or compulsive behaviors can be high. Reserve carbidopa/levodopa for intermittent use. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Asenapine’s claim to fame is its availability in both sublingual and skin patch formulations, so it’s a good choice for patients who can’t or don’t want to swallow a pill. Mouth numbness (Saphris), sedation, dizziness, akathisia, weight gain, and potential for allergic reaction are significant liabilities. Not recommended for first-line use.

Elevated prolactin levels (>29 ng/mL in nonpregnant, nonlactating women, >18 ng/mL in men) that can cause the following symptoms: ⦁ Women: Menstrual irregularity or amenorrhea, infertility, lowered libido, galactorrhea, decreased bone density, increase or thickening of hair in unexpected areas such as face. ⦁ Men: Breast enlargement (gynecomastia), erectile dysfunction, low libido, infertility, galactorrhea.

Light therapy is an effective treatment for seasonal affective disorder (SAD) and possibly for nonseasonal depression as well. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Propranolol has several uses in psychiatry, including performance anxiety, drug-induced tremor, and akathisia. Some clinicians favor it as an “as needed” drug for a variety of anxiety issues, especially when benzos are contraindicated. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Deutetrabenazine was the second of the VMAT inhibitors to be approved for the treatment of tardive dyskinesia (TD) in 2017. Its advantage over off-label tetrabenazine is less frequent dosing and less likelihood of causing depression. However, it is extremely expensive—about $7,000/month as opposed to $700/month for tetrabenazine. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Like Daytrana, Xelstrym is helpful for those who, for whatever reason, cannot use any of the wide variety of oral stimulant preparations. Otherwise, we don’t recommend it due to high cost, lag time for onset of effect, and the side effect of rash, which is pretty common and unpleasant. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).